FAQ: How to Find the Primary Physician in Claims

by Karen Wolfe

A frequently asked question in Workers’ Compensation medical management is, “How can one determine which is the primary physician in a claim?” The reason for the question is usually an attempt to assign accountability for the outcome of claims. However, the question, if asked slightly differently, can provide much more valuable information.

The wrong question

Whether or not the correct question is asked, gathering information about treating doctors is essential. Knowing all the treating doctors in a claim is important and they can be easily found through analytics (data analysis). However, determining the primary doctor is misleading.

The notion of primary physician suggests assumptions that are inaccurate: that the primary physician has control of a claim. Rarely does one physician have full control. But one physician might have the most influence. Therefore, a more telling question is, “Who is the predominant physician in the claim?”

Predominant physician

The predominant physician in a claim is the one who has had the most influence on claim cost and outcome. That information can also be found in the data.  However, predominance cannot be measured in dollars billed or paid to physicians. Specialists, especially surgeons, will surface using dollars as the identifying metric. Those identified may or may not be the most influential in the course of treatment or outcome. Predominant physicians are the ones who encounter the injured worker most frequently.

Influence and Impact

An indicator of physician predominance in the data is how frequently they were face to face with the injured worker. Frequent encounters with the same physician will significantly influence the course of the claim, leading to positive or negative results. It is one measure of medical provider performance.

The treating physician who is seen more frequently by the injured worker will impact return to work, recovery, and often directly influence whether the claimant seeks litigation. Identify the best physicians using predominance in the claim data as one factor. Rather than directing injured workers to any physician in the network, select the doctors with better results, especially those who have greater influence in claims with positive outcomes.

New networks

Traditional discount networks do not evaluate provider performance regarding claim cost and outcome. Employers and their claims administrators are now undertaking that task and redesigning their networks by carving out the best performers. The only sure way to do that is to examine the data, especially provider performance data measured by multiple indicators. One of the indicators that should be evaluated is physician predominance in claims.

A groundswell is occurring in Workers’ Compensation, a dramatic shift from traditional medical provider discount networks to quality, outcome-based networks. Increasingly more organizations are evaluating their providers in networks and carving out the best-in-class doctors. Creating a “designer” network of the best doctors by analyzing the data guarantees improved claim outcomes.

Karen Wolfe is the founder and president of MedMetrics®, LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics applies analytics and technology to evaluate medical provider performance, to significantly strengthen medical management in Workers’ Compensation, and to link the analytics to operations by means of user apps, thereby making the analytics actionable.